Disparities and inequalities of penicillin allergy in the Asia‐Pacific region
Authors: Philip H. Li, Ruby Pawankar, Bernard Y. H. Thong, Hugo W. F. Mak, Grace Chan, Wen‐Hung Chung, Meng Juan, Hye‐Ryun Kang, Byung‐Keun Kim, Rommel Crisenio M. Lobo, Michaela Lucas, Duy Le Pham, Thushali Ranasinghe, Iris Rengganis, Ticha Rerkpattanapipat, Munkhbayarlakh Sonomjamts, Yi‐Giien Tsai, Jiu‐Yao Wang, Masao Yamaguchi, James Yun
Journal: Allergy (2023)

The overwhelming burden of penicillin "allergy" labels remains a global public health concern associated with a myriad of adverse clinical outcomes.1 The epidemiology and sensitization patterns of penicillin allergy varies greatly and remain largely unknown in the Asia-Pacific (AP) region.2-4 This international survey was performed to investigate the epidemiology, healthcare infrastructures and clinical practices pertaining to penicillin allergy in AP. A 25-item questionnaire (with additional questions for selected answers) was distributed to representatives of countries/regions of the Asia Pacific Association of Allergy Asthma and Clinical Immunology from July to October 2022. In total, 16 questionnaires were sent to experts from Australia [2 questionnaires], China, Hong Kong, Indonesia, Japan, Mongolia, the Philippines, Singapore, South Korea [2 questionnaires], Sri Lanka, Taiwan [2 questionnaires], Thailand and Vietnam. All invitations were replied with a valid response, representing 13 (87%) countries/regions, which were classified as "Advanced Economies" (AE; Australia, Hong Kong, Japan, Singapore, South Korea and Taiwan) and "Emerging Economies" (EE; China, Indonesia, Mongolia, the Philippines, Sri Lanka, Thailand and Vietnam) according to the International Monetary Fund (Table 1). Variables were then compared using Fisher's exact tests on IBM SPSS Statistics version 28.0 (IBM Co.). p-Values <.05 were considered statistically significant. Collectively, the represented population of surveyed societies was 2.3 billion, equivalent to 28% of the global population of 2022. Differences in healthcare infrastructures between regions with AE and EE are shown in Figure 1. Less than a third of respondents (31%), had drug allergy registries, which were only established in AE but not EE (67% vs. 0%, p = .021). Availability of local or regional guidelines (100% vs. 17%, p = .015) and nurse-led testing (100% vs. 25%, p = .048) were significantly more likely to be available in AE than EE. For investigations, 55% had their own specific protocols or guidelines on penicillin allergy, which were typically involved or led by doctors (100%), nurses (67%) or pharmacists (11%). Penicillin allergy skin testing (ST) and drug provocation tests (DPT) were available in all (100%) and 91% of centres, respectively. In vitro tests, namely, basophil activation test, lymphocyte transformation test and enzyme-linked immunosorbent spot, were only available in AE (in 27%, 18% and 18%, respectively), while no in vitro tests were available in any EE. For ST, benzylpenicillin (71%) and amoxicillin (64%) were the most widely employed reagents. Penicilloyl-polylysine (PPL) and minor determinant mixture (MDM) were routinely performed in 43%. The reported overall rate of ST positivity was 13% (1%–30%). Among positive ST, PPL and/or MDM was positive in 37%, ranging from 1% to 94%; while amoxicillin was positive in 39%, ranging from 3% to 70%. The reported positive DPT rate was 23% (5%–80%) and the overall delabelling rate was 72% (10%–90%) among patients who fully completed evaluation. Our survey revealed significant disparities and inequalities between EE and AE regarding penicillin/drug allergy management. Non-allergist or nurse-led penicillin allergy delabelling strategies have alleviated limited specialist resources and even demonstrated superior outcomes to traditional allergist-led evaluation among AP populations.5 Similar strategies should be employed in more AP countries and inter-disciplinary collaborations should be encouraged. Furthermore, there was huge heterogeneity among the region with vastly varying rates of ST/DPT positivity as well as overall delabelling. This may be due to a lack of standardization of practice, pointing towards the needs for regional consensus and guidance. Similarly, collaboration or conglomeration of drug allergy registries (especially for countries unable to maintain their own individual registries) would also be essential to inform and prioritize more specific needs pertaining to AP. This survey serves as an impetus for further investigation and collaboration regarding strategies for addressing penicillin allergy within AP. Especially given the disparities between AE and EE, further international collaborations are urgently required to improve overall access to high-quality, equitable allergy care for patients of the AP region and beyond. There was no funding for this study. None of the authors have any conflicts of interest in relation to this manuscript.